Improving Westerosi Maternity Services - Every Mummer Counts
Women in Westeros get a bad deal and is this most evident in it's shocking maternal mortality rates. Whilst definitive statistics are difficult to come by there is a rich stock of qualitative data from documentary series "Game of Thrones". It shows that childbirth is dangerous and pregnancy gives no reprieve from the violence of the world.
The first major problem is access to basic medical care for even the most highborn of women. Arguably the root of Robert's Rebellion was the fact Lyanna Stark, though surrounded by willing servants in a prestigious tower died from a post partum haemorrhage. Adequate access to uterotonic medication and availability of those suitably trained in repair of perineal trauma may have averted such a tumultuous period in Westerosi history. The stigma for survivors is also a burden to be borne. Tyrion Lannister born without access to pre-natal USS screening to actively manage the pregnancy led not only to Joanna Lannister's death but also a lifetime of scorn from his remaining family.
It is no better across the Narrow Sea where perinatal mortality is also worryingly high. Added to this we have proof of non evidence based blood magic from unlicensed Maeges have been responsible for the stillbirth of Daenerys Targaryen's child. It is important that any new process or therapy is rigorously peer approved and based on sound scientific evidence and the risks of alternative therapies are communicated to women and consent gained accordingly.
The stories here are just the affluent tip of the iceberg. There will be thousands of stories of less privileged women dying in poverty due to lack of access to midwifery care and sanitation.
That's not to say there aren't successes. There is documentation of multiple births north of the wall at Craster's Keep and indeed the Queen on the Iron Throne has successfully delivered 3 children under dubious lineage. Consanguinity as a protective factor could be an interesting topic for further research?
Maternal Mortality statistics also contain deaths from indirect causes, which commonly seems to be deaths from domestic violence. This includes the recent death of Walda Bolton and her newborn son. Having successfully traversed a high risk pregnancy with a raised BMI, care in post partum time should include a thorough domestic violence risk assessment which would have surely have picked up on the dangerous individuals in her household. Without robust systems and social services in place these vulnerable people were let down by the crown.
Calls are then made for access to those with formal training in childbirth and maternity care. This surely must fall into the remit of Maesters who are ideally placed to lead maternity care. They have anatomical and pharmaceutical knowledge to make a real difference in the delivery of maternity care. However they have their own issues before being made part of the maternal health team. Being very secretive with their knowledge is not the right way to go about healthcare innovation and they would need to embrace a more open non-blame culture in improving outcomes. They would also need to evaluate their own practices against current trends to ensure that Maesterising birth doesn't lead to poor outcomes and a loss of maternal choice in their birth decision making. Lastly, for too long women's decisions are being taken by men so the archaic bar to women joining the Citadel must be reversed in order to allow women to care for women and be armed with as much up to date information as possible.
There is reason for cautious optimism with a woman on the Iron Throne women at the head of many powerful families currently, the time is right to allow the establishment of midwifery as a right for every pregnant woman in Westeros. Couple that with access to evidenced based maester led high risk care. What good is war if there is nobody to carry on the family lineage? Allocation of recently acquired gold would go some way to show the people that women's health is taken seriously by the current administration.
Election Dissection: This time it's Personal
2017 General Election represented my first foray into national electoral politics. I had stood as a paper council candidate for the Green Party in the 2017 local elections but this was obviously a much bigger deal. I have written about how the Green Party did nationally here but also wanted to look at my own performance and plans for the future.
When people ask how on earth did I get into this, there was no magic moment, just a series of small events which lead to standing for Parliament in my home town. In 2015 when I moved back to Northampton, I had voted for Green Party at the 2 previous elections and decided in that summer I wanted to get more involved with local politics, seeing as my knees were no longer up to Sunday league football. So I joined the Green Party and attended the September 2015 Party Conference, which was fantastic, but due to work, didn't manage to make it to any meetings that year. Then in 2016 I attended an event protesting against an incinerator being built in the town with support from Northants Green Party. It was here I met local activists and resolved to attend meetings to see where I could help.
After a couple of meetings we had our AGM where the chance to run social media and website came up, which I took up in September 2016. We then organised attending events and marches for the NHS, Pro-Democracy and Anti-War causes as well as local air quality testing. I was asked to be a paper candidate in the 2017 local elections, which just provided a chance to vote Green in my area. There was no campaign, although I did help out with the campaign for our target ward in Northampton. Then the snap election was called, and despite having selected 7 candidates back in 2016 on the hunch a snap election would be called after Brexit, we had 3 vacancies for General Election Candidates in Northamptonshire. I expressed an interest, made a short speech at our selection meeting and there I was!
So, what happened next?
Election was called on 18th April, I was selected on 2nd May, attended local election count on 5th May and submitted my application to local electoral services on May 10th, having not managed to agree any Progressive Alliance locally. I had put up the £500 deposit from combined party, crowdfunded and personal funds there was not much time or money to run a large campaign. This not being helped by continuing to work my full hospital commitments.
I set up a Facebook campaign page and churned out tweets, videos and updates. I answered hundreds of lobbying emails and pledges to support various causes. I went on as much media as I could manage, radio, TV, newspaper hustings. I visited my old school and supported national campaigns. I posted about 5000 leaflets with the help of a number of local volunteers, who I am massively grateful to.
Now, regular readers of my blog will know that if somebody were to ask me what my biggest weakness was, I'd say "Job interviews". I'd just signed up for a public job interview which will last 4 weeks. So, way to face up to them fears!
I think that I honestly put about as much into the campaign as I could. I'm not happy with the outcome and some of that is due to a national trend of a reduction in Green vote and rise of an actual Left wing Labour party. Part of it I think was due to my limitations as a candidate, not only financially but with free time and getting my message out. I was aware that we needed a distinct message from the Labour Party but unfortunately too many of my answers at hustings began "I agree with Kevin...". My family and friends were a great help but I didn't want to put too much on them in terms of door knocking and leafleting so much of that I took on myself. We didn't have an army of door knockers or reams of canvassing data. I didn't feel I had the money to put out a full free post leaflet to every constituent and unfortunately did hear murmurs that some people didn't know a Green candidate was standing. I was also a bit miffed that media outlets like ITV news would interview the other 4 candidates but not me, especially as in terms of votes, 3 of the 5 of us were fairly close.
I know you should never watch yourself give media performances but I looked hesitant and nervous about putting a point across which was usually a good point! The hesitancy is me though. It's who I am. I run everything I think through a filter as I'm worried what people would think when it comes out. When I'm tired or stressed sometimes the filter doesn't work! At least I can say that all of my media performances were authentic and not somebody else. I think I got better as I got more into it, but with only 4 weeks there wasn't much time to warm up.
So, what happens next?
Firstly, it's my annual appraisal later this month (ARCP) which decides if I've progressed enough this year as a doctor to be allowed to go onto the next stage of specialist training. There are still some things to tidy up from there and work to be done.
As for the Green Party, we've got a lot of thinking and work to do. It's clear by our vote share that our message wasn't getting out or convincing enough. The Green policies I like the most are the ones we don't share with Labour: Citizen's income, Nuclear Disarmament, Soft Brexit, Proportional Representation and commitment to leaving fossil fuels in the ground. However these weren't what the election was about. Corbyn shut Brexit off as an issue by essentially agreeing with the government and the important issues of the electorate: - Social care, Education and the NHS we didn't offer an alternative to Labour policy.
What I want to do next is figure out how we can do better next time, given our limited human and financial resources. Personally, I enjoyed the whole thing and would thoroughly like to do it again. I just don't like losing so hard. The Green Party target to win policy I think is the way forward. As a local party with maybe 2 dozen active members, for the 2019 local elections, I think instead of running many campaigns in a low power way, perhaps we need to focus our attention in 1 area to get maximum gain. That would mean me volunteering by leafleting and door knocking in one place with ALL the other candidates and members in just one or two wards.
I'd also have to change the type of work. Seeing the 2 main parties campaigning threw into sharp relief the size our tasks. They proved that you need boots on the ground not only to leaflet but to door knock and get canvassing information. That is something we could be doing all year round, and will try to attend a Green Party canvasser course in the near future. If we have 5% of the activists we need to focus our efforts in a smaller area to make a gain. Even a single council seat in Northamptonshire would be a huge improvement not only for ourselves, but for the voices of locals who see a sea of blue through all the diesel fumes.
We are at our best when we are local, visible and vocal, which with regards to air quality I think we are. I think we ought to champion this issue across the board for all of our active local measures and direct efforts to getting more air testing data, more time at council meetings and more local support. We could start a "Green Business" group, to promote businesses which have an environmental angle or do something good in the community, which could hopefully attract business and sponsorship. Every chance to get in local media to show we are doing something, whether that is fitting new air tubes, picking up litter or turning up en masse to cabinet meetings.
Personally, I could get more involved with my hospital and community groups to help with issues we might be facing. My current role as BMA rep it appears that our major issue is parking. Campaigning on something to address this like a park and ride for example could be the way forward. In my own ward, I want to be attending parish council meetings and trying to figure out what is happening with development (or lack thereof) of the St Crispin's Hospital site which has lay derelict for the 2 years I've lived there. I'll be putting these ideas to our post election meeting tomorrow, so I could end up doing a lot of work whilst continuing my O&G training, which as my sole income and life for the last 13 years is no small priority.
I think there is still a future for the Green's, we just have a grab it work harder for it and make each Green activist count double with the work we put in!
Theresa May is terminally damaged by arrogantly calling an election on the issue she wanted, Brexit. Whereas the electorate rightly voted about policies, where the Tory manifesto was found wanting. Her leadership proved to be anything but strong and stable, and she's going to limp along with the help of some climate change denying bigots.
Labour lost this election, just not as badly as everyone thought they would. They are over 60 seats short of forming a majority government, despite gaining seats in key marginals. Corbyn may have grown as a leader and won some young voters, but will the legion of no confidence voting MPs suddenly have discovered a love for him? Against all odds Labour appeared to have won some seats, have they got it in them to do it again later this year?
The Liberal Democrat land grab of the remainers didn't bear the fruits first thought and the echo of their Europhile drumbeat will ebb away as Brexit negotiations continue. Even strong remainers like myself, just want to see it done with in a quick and painless a manner as possible. Delaying things will just put on hold the fact that we need to remake our country in a fairer way and sort out our environment and public services.
UKIP may have fell away considerably, but their supporters didn't exclusively flood to the Tories. Again, once Brexit is over what is there for them to campaign on? I imagine they will adopt more right wing, anti-immigration dog whistle politics to differentiate themselves from the Tories.
SNP having hit a zenith last time out, were never going to do that well again. The issue of Scottish independence spooked people into voting Tory in Scotland for the first time in my lifetime. I think they have about hit their mark with vote share and seat number.
As for us, The Green Party didn't do well even by our own measurements. Sure, Caroline Lucas was returned with an increased majority and we got half a million votes nationally. Our aim was 2 MPs which we didn't seem anywhere near getting in our key targets of IoW, Bristol West & Sheffield Central. We also only got half the votes we did last time out. The reasons for this I think are the lurch to the left of the labour party where there was significant crossover with policies we've held for a long time such as scrapping Tuition Fees and renationalising the railways. This meant people who joined the Greens because there wasn't a progressive left wing party around any more felt comfortable to go back to labour. Also a small party with a campaign short on resources and canvassing data was never going to perform as well as during a normal electoral cycle.
We also have an issue with the Progressive Alliance policy. I can see why we do it in that we are a smaller party and would rather have a labour government than a Tory one; but I'd rather have a Green one than a Labour one! We unilaterally stood down in seats as a show of good will hoping others would see it's benefit and it wasn't reciprocated. It won't be reciprocated, that much is clear. Any sign of Labour doing deals with us, overtly or covertly will be seized upon as weakness by the press and or Tories. It seems any co-operation we do is expected across the board.
Personally, the only online grief I received for standing for parliament were from Labour supporters who thought I shouldn't be standing. Not once did they try and tell me about how great their policies were or why we should vote for labour, just "waste your vote on Green" "A green vote is a Tory vote". You win votes by having better policies, not bullying smaller parties into oblivion. We are very different to the Labour party, they've moved their policies towards us, not the other way around. We don't want to fund nuclear war or go ahead with leaving the single market or continue with environmental inertia. I also think, many of our remaining voters wouldn't automatically go to labour. I think many would abstain or spoil if we aren't on the ballot, as many vote Green as they are disillusioned with mainstream electoral politics.
The way I see it, we have 4 options nationally going forward and none of them are perfect. The current half measure hasn't worked, I can't see the status quo happening again where we do all the stepping down and get very little in return. I also wouldn't want to do what a couple of friends of mine in Momentum would like, which is to become the Environmental wing of the labour party and trade our identity and policies in for a few former Greens getting Labour seats.
We could double down on Progressive Alliance, formally support Labour where we don't stand and stand down in 100s of seats. Not only to stop a "split the vote" situation where we lose 100s of deposits but to focus national resource at getting more Green MPs in places they might actually get elected. This might get us another MP and a chance to push proportional representation, but risks alienating Green's nationally. Or we abandon the notion all together, stand wherever we can and show voters that we offer a different vision to all of the mainstream political parties and be proud to do so. This might get us a wider reception but would probably keep our vote share in the low single figures range.
The elephant in the room is the First Past the Post electoral system. It's defenders say it keeps out extremists and provides decisive government. On evidence of the most recent election, it has done neither. The other defence of FPTP is that it maintains a local link to your MP. In the seat I stood in, the address of the new MP on the ballot is 60 miles away. Democracy doesn't work if large quantities of people's vote just don't matter and for 500,000 people we get 1/650th of the voice in parliament. All efforts in cross party co-operation must have proportional representation at it's heart. I'm not sure which way we Greens should turn next with regard to PA, but it needs to have change the entire voting system at it's heart.
The FT have done some excellent graphs about changing demographics and voting trends. I recommend you give it a read!
A Difficult Conversation
Anyhow, I started as I meant to go on and picked up Atul Gawande's "Being Mortal". I thought this was a safe place to start as his other book I read "The Checklist Manifesto" was so good it changed the way I worked in the operating theatre. Going from sighing my way through the WHO checklist to making it a central part of being in theatre. Gawande is one of those people who seems to be able to do anything. An accomplished surgeon, writer, NGO and public health leader. In fact if he played for United he'd be the picture at the bottom of this blog!
Its about how medicine has changed the way we experience ageing and death and the things people around America are doing to try and improve this situation. He tells a story of not wanting to confront a young patient's impending death from lung cancer by using euphemisms, and how difficult it was to actually bring up the subject for the doctor. Instead talking about "putting this issue aside so we can focus on the lung cancer". This resonated so much with my own experience of these conversations and I had an example where I ended up having a difficult conversation, in a situation you wouldn't normally expect.
The junior doctors usually have the job of clerking in elective patients for day case procedures. Usually it's a quick chat, write up their regular medication and make sure their consent form and blood tests are up to date. This case was unfortunately a young patient with advanced ovarian cancer coming in for an ascitic drain to relieve the discomfort of having fluid build up in her abdomen. Her cancer was incurable and she had tried 2 types of chemotherapy without success already.
I duly went through her medical history and medications, which were surprisingly few for someone so poorly and noticed she was on a statin. A statin is a drug that lowers cholesterol and can help prevent strokes and heart attacks if given to enough people over a long enough time period. The patient told me that they gave her nausea but stuck with a low dose because it was good for her in the long term. This is right, but things had changed since she started on her cancer journey.
The easy thing to do would be chart the statin and get on with things but I asked if she wanted to carry on taking the medication. I struggled to find a way to say "why take a drug that makes you feel ill and won't help you because you'll be dead from your cancer before you get the benefit of the statin" without sounding horrible. So I tried to see what her understanding was about statins, and she seemed clued up and then seemed to stop and then was to the point for me:
"The cancer will get me before a heart attack will, won't it?"
I gave a non-comittal grimace and suggested she could stop it to see if it helped her nausea. She stopped the drug and when she came back a few weeks later for another drainage, she told me she felt slightly better from a nausea point of view. It showed that having difficult conversations are actually be worth it for patients and we as doctors tend to practice with inertia (especially if another doctor started the medications). Helping patients make sensible decisions about preventative medications is a small part to play, but showed tackling these may help in the long run.
So, just like the Checklist Manifesto changed my operating pratice, it looks like Gawande's next book will change how I practise medicine in patients who are terminally ill.
Oh, and if anyone wants a copy of Paul Mason's Post Capitalism, I have a spare!
The BMA Bop
After 6 weeks nobody had gotten back to me from the BMA so I assumed that they had found someone or hadn't got my email. If a week is a long time in politics, 6 weeks is an age. In this time the BMA had gone from losing a ballot, declaring strike action then cancelling said strike action. It was fair to say I wasn't overly enamoured with them as an organisation for declaring strike action then cancelling it in quick succession. They were entirely right to call action if 58% had not accepted the contract, but where the 4 x 5 days figure was plucked from and why it was called off I'll never know.
It was therefore to my immense surprise when I receive an email saying I had been voted in as JD rep at their meeting (which I hadn't attended and didn't know about) as nobody else had come forward. So in late September I was made junior LNC rep and had to hastily organise a picket and ensure departments could cover their work. I figured the situation must still be salvageable at a national level (despite only hearing about press releases through BBC) so I decided to give it my best shot.
I started by trying to gauge reaction to the idea of 5 days of strike action, in order to represent the views of local members. If you look back to my previous post I had originally planned not to strike. This was due to the financial implications of losing potentially 4 weeks pay as well as my training record; Health Education England had sent us an email reminding us we may fail our training appraisal if we missed more than 2 weeks of work. I sent an email out to all junior doctors and spoke to the juniors in my department of O&G as well as nearby specialities like paediatrics and anaesthesia. I also tried to get a view of the FY1s at their teaching sessions. From my conversations I got the impression that nobody really wanted to strike for 5 days even those who had voted the contract offer down. From my email to 150 doctors, I received a solitary reply, echoing these sentiments.
I had gone from someone who was not planning to strike and wavering on whether to keep my BMA subscription going to somebody visibly representing the BMA within the hospital and trying to organise a picket. Then it got very difficult for me. The job lot of strikes was cancelled (again I found out via BBC) without anything in it's place and without an explanation. I enquired higher up and advised that a JDC meeting a month away would clear everything up. At this point O&G registrars were being started on the new contract. It appeared there was no going back. But hey, at least we got the now infamous stickers in the post to proudly wear whilst nothing happened.
|The stickers that launched no ships at all|
So whilst the JDC were navel gazing I had to face my colleagues at the junior doctor forum and tell them that I knew nothing about the cancelled strike action and no plans were in place. I was rightly given some upset words from my colleagues. I waited for news of our next move, my proud sticker starting to curl on my lapel. The next meeting of the JDC only served to lose another chair. I waited some more and on radio 4's today show Dr Porter effectively ended our dispute with the government. With the new chair of JDC assuring us we are still in dispute and are back at the negotiating table, you can forgive me for not holding my breath.
In the absence of any guidance I made a decision at this point to work with the trust to ensure that they had all the statutory systems in place required for the contract to be imposed, and hold them to account if they didn't. It is to be said that the trusts are innocent bystanders in this and with pay protection actually stand to lose a fair amount of money over the next few years because of the new contract. Here is where I feel I've actually been useful as a BMA representative.
Along with the very helpful Industrial Relations Officers I have been involved locally with almost every aspect of the new contract. I've helped to appoint a guardian of safe working, I've tested and decided on which exception reporting software is to be used. I've looked at FY1 rotas to ensure they are compliant. I've broken down the contract and it's minutiae with our first cohort to be imposed upon to reassure them that nobody is getting a pay cut or a change in their rota. I've reviewed the equality impact assessment from the trust - interestingly it being inherently unfair on LTFT workers was not mentioned. We've agreed with the trust to postpone most doctors going onto the new contract until August 2017.
My hope is that the contract is an unworkable disaster. The exception reporting relies heavily on educational supervisors to discuss and change work schedules as needed, which is all potentially a lot of new work. They will receive no extra time or money for this. Trusts may well find educational supervisors sign off exception reports as one-offs and give the payments to the doctors as it is the easiest way to solve the problem. Once the money starts accruing we might see something positive happen in terms of working conditions. I would therefore recommend any junior doctor reading this to fill out exception reports for EVERY alteration to your work and training schedule and then keep hassling your managers, supervisors, medical staffing and payroll to get every bit of extra money you are owed. Your BMA rep should help you with this. If you are an educational supervisor I suggest you lobby the consultant negotiators to increase the time in your job plan for educational supervisor activity or vote with your feet and stop being a supervisor if the work is too onerous or not remunerated enough. If enough people are annoyed and enough money is being lost then government will have to listen. I fully intend to pile up exception reports on the trust, as the juniors at every hospital I've ever worked at, work above and beyond their "rostered hours". It's not unprofessional to be paid for what you work and the well of goodwill has run dry.
So considering I wasn't a fan of the JDC I still think there is positive work I can do for juniors locally within the BMA. I believe in Unions and being a BMA rep isn't just a line on my CV. I've been on the JD Facebook forum and there is a lot of ill feeling towards the BMA. Good. Once again, people need to vote with their wallets or nothing changes. If they start losing money by cancelled subs then they might realise they can't get away with treating our contract negotiations like a student debating club. There is a lot unharnessed anger on there but words (he says writing a blog), twitter rants, stickers, YouTube raps and candlelit vigils achieve very little.
It leads me to wonder what I would change about the BMA as clearly they have missed the mark nationally with the JD contract negotiations. As far as I was concerned the JDC were doing a great job up until they embarked on a roadshow to get a "yes" vote in June's contract referendum. It was this point they could have just accepted the contract or kept neutral in any referendum campaign. Then on getting a no vote they could have continued with the 2 day strike actions that had worked earlier in the year. The BMA isn't just a union, it's statement about Scottish Whiskey today shows that they try to be public health watchdogs; which is what I thought Public Health England were. I wonder if the make up of the JDC sets us up to fail. We are all unpaid volunteers with medical careers which as far as I know trump our role as BMA reps. It therefore is natural that having such a major national role for JDC can be full of distractions and conflicts. I'm not sure about this but I don't think the JDC chair gets to work on the job full time and take time out of training. Maybe having more legal or union minded non medics or even full time medics seconded to the role full time for a period may help when developing a negotiating strategy. Lastly, the communication from BMA is patchy and leaky at best. Their email server tends to send mail out in slow batches so people get news in dribs and drabs, when we were getting news at all. I like the step that the new chair as taken to get himself added to the regional chat forums in order to get news and views directly to him.
It was always going to be difficult job not to get screwed over as eventually I want my certificate of completion of training and already put up with a lot to get it. If there is a silver lining then the May 2016 contract is a sight better than the November 2015 contract and I'm not too ashamed to throw away my BMA badge holder. You never know where I could end up if I fell into this role so accidentally. I hear the catering at BMA house is fantastic; it must be as it comes out of my considerable subs!
As my twitter feed and previous posts here show, I wasn't too enamoured with the idea of the government imposing a contract that would result in worse hours and less pay. I went on strike in January and again in April. I waved a placard, canvassed for the BMA and put my point of view across on social and old school media.
Next week I won't be on the picket line.
The first reason is simple, I can't afford to lose £600. The other reasons are slightly more elaborate.
After ACAS negotiations the BMA emerged with what they said was a decent, albeit not perfect offer from the government. Upon reading the revised deal, I could see it was a vastly different contract to the original contract that was due to be imposed which I went on strike over. I attended a BMA road show where I was told that my concerns about a pay cut, unsafe hours, part time workers and reduction in pay progression had been addressed. New hours safeguards and adherence to EWTD were in place. A guardian of safe hours was to be implemented. An online hours breech system was to be introduced to accurately reflect how much we work. The BMA said this was the best they could get and we should accept it. I duly accepted it in the most recent vote. 58% of my colleagues didn't.
My colleagues have that rejected that contract offer can strike and do so with a clear conscience that their demands weren't met, and I support them. My conscience will not allow me to strike over a contract that I was willing to accept. This also leaves me looking somewhat like a government stooge which I'm very much not!
The fact that the contract is still felt to be discriminatory to women, part time workers, academics and career changers (like me) seemed to be lost on the BMA at the time. Why couldn't they use their considerable resources to have the contract reviewed by the country's top legal minds? Why not re-ballot about whether 5 day strike action is the way forward. Conversely, why bother with the "referendum" at all if the contract offer was so good. Why come out so in favour of the contract initially and aid implementation when the response to losing the referendum was to undertake more intense strike action than before?
For me the contract was always about pay, but we seemed to be too scared to say it. It was always about pay but not in the direction some people think. I'll say it again because people don't seem to get it.
I DON'T WANT A PAY CUT, I AM NOT ASKING FOR A PAY RISE,
The thing is pay IS linked to conditions and getting the same pay but working more difficult hours IS linked to patient safety. They are not separate issues. We shouldn't have let the narrative get shifted to "Lazy, greedy doctors want more money!". It think the BMA have been outmanoeuvred by the government and now news outlets are running negative stories and the BMA appear off the pace. They look silly now that they are striking on a contract they took great effort to endorse. Don't blame on malice what can be explained by incompetence.
The problem with more strikes is the possibility that this is used by the government to preface further erosion of the NHS as a free healthcare system. Rota gaps and service closures are de rigueur and all this can create a picture of a service in chaos. I posted lots of ways we could have had industrial action that wasn't all out strike, even in my BMA feedback but this is the way it's gone.
The market value of my service is more than I'm currently paid as I work in a monopoly, and a I take that difference because I like working in a service that places patients and not money first. Even though I want to keep the NHS, paradoxically a private system would benefit most doctors financially. Market forces can't apply to me as I only have 1 employer option if I ever want to be a consultant so any strike action was never destined to last more than 2 weeks. Any longer than this and I would not be passing my appraisal for the year.
So what was my solution? We use the systems in the new contract to our advantage. Currently when I work late because I'm helping a patient I don't spend more time filling out overtime sheets or "breach forms" as nothing useful comes from them and I definitely won't get paid any more. New proposals to link e-rostering for our shifts and actually pay us a proportion of current trust overtime charges and would mean filling out these forms could actually make a difference. I jokingly used to count up all my unpaid overtime and call it my "NHS Goodwill Fund", but it stopped being funny after it quickly started mounting up. This is overtime not because I'm lazy or slow, but because patients are sick, theatre lists and clinics are crammed and there are definite rota gaps.
Much like when GPs shocked the government with their excellent adherence to receiving QoF payments I think junior doctors should have strongly adhered to new e-rostering rules and tell hospitals how much they are working and pester their "Guardians of Safe Working" to be paid for all of this extra work they are doing and the BMA would have something to work with. I estimate that the government thinks we don't work as much unpaid overtime as we do and 50,000 doctors showing their time receipts and giving hospitals big bills for this overtime is the way forward.
I think the contract issue is unwinnable as I will definitely still be working for my CCT and will end up sign anything put in front of me to keep my training number and mortgage paid.
So, overall I won't be striking, but I don't condemn my colleagues who will be, and I hope the public doesn't haul too much abuse at them. After all the public won't know how good they had it, until it's gone.
Personal Strike FAQ
Since the new junior doctor contract hit the headlines about 6 months ago, I've been asked my opinion by medical and non medical friends alike. Most have been supportive, some confused, a few not supportive. I thought I'd direct them to a FAQ so I didn't have to keep repeating myself.
Why do you want to strike?
Like a good politician I will not actually answer the question, I will answer the opposite of the question to appease people who think I'm greedy.
I DO NOT WANT A PAY RISE.
OK, now I've cleared that up, I'll answer the actual question.
I can see why the BMA wants to keep the narrative about patient safety, inability to cover rotas (seeing as we can't already) and discrimination to women and part timers. However for me when it comes down to it, I do not want a pay cut. As a trainee who has changed career I have benefited from pay progression in my years as a surgeon. With pay progression scrapped for career changes and academic trainees will doubly affect me. My argument for keeping pay progression is that my experience in surgery has positively affected my work in this post pretty much everyday. The pregnant lady who I knew had appendicitis from her walk across the waiting room probably agrees.
Seeing as my rota is not changing my previous post explained how I might get a pay cut. As a single income household with 2 kids and a mortgage I really don't fancy losing nearly £5k a year. I actually think a pay cut should be enough of a justification for industrial action but there we go. Entitled doctor opinion or not. Vocation is a wonderful thing which I have in spades, but unfortunately it isn't legal tender.
As I need to break even to pay my mortgage, my solution to the pay cut would be to work more locum shifts. This sort of shoots any "I'm really worried about the amount of hours I work" argument out of the water. However caps to locum pay would mean almost a 50% cut in take home locum pay. The free market should be allowed to be free, except for public sector workers.
The other thing is that would sort of go against having another agenda for wanting to strike is a hypothetical situation where we were given the current contract and complete loss of hours safeguards but we'd all be paid 80 grand a year. Do you think we would all be out on the streets? I wouldn't be.
As it happens I agree with the wider argument from the BMA that the junior doctor contract is one facet of a wider campaign to undermine the staff in the NHS in an attempt to open it up to private investment. Others including getting rid of bursaries for student nurses and the health & social care act. This happens to be a convenient vehicle to voice concerns in general.
So you agree with the strike action, Why are you scabbing then?
Almost exactly the same answer. MONEY
I'd love to say my intense desire to keep my patients safe compelled me to cross the picket line. That was not really the case as at no point were any inpatients in any danger during any of the strikes.
It is the fact that I would lose £200 a day for each strike day that is what compelled me. When you are borrowing money from your Dad to pay your MOT and spending every other "rest day" in A&E locumming, losing £400 a month is quite a hit.
I was quite happy to work and let my colleagues strike, ones with no kids or money worries. You could say it is short sighted to not strike when you stand to lose out in the long run. That is what the government wants unfortunately, and my bank manager won't accept late payments because of my staunch principles. I can't afford jam today, so I'll worry about today now and worry about later, later.
What would it take to get me to be happy with the contract?
Well, I'm not really sure, which is why I've put my faith in JDC to negotiate for me. Probably a complete reversal and no change would satisfy me, but that isn't going to happen.
The problem with the old contract is that banding payments only have a few levels (50% 40% 20% 5% and nil) and this meant that people working wildly different hours could be paid the same. For example as a surgical registrar I worked a partial shift pattern with overnight on calls. The urology registrar worked every other Saturday and no nights. We were on the same salary. The new contract won't address this issue as the pay cuts will mostly affect those that work the most unsociable hours, making people like myself in Obstetrics worse off and people in day time "office" specialities better off.
So essentially, I'll be happy if the BMA are.
What would a 7 day NHS look like?
I don't know, and that is the problem. There have been no sample rotas, no plans to open clinics or theatres at weekend, no plans from our trust about how we will provide this "Truly 7 day NHS". What is the point of introducing a new contract if we don't change our working patterns. When I'm operating an elective list on Saturdays have the trust got plans to pay for ODPs, porters, scrub nurses, support workers who also need to be there? I don't think so.
Salford has managed to provide excellent 7 day emergency access to MRI etc. and have a Standardised Mortality ratio of 88 (This is good). They have done this with current staffing and contracts.
Didn't we pay for your training?
Yes, you did, and bloody good value for money as well. I'm old and lucky enough to only have £25k of student debt and the taxpayer put up about £175k over 5 years. That's quite an investment. One solution would be a golden handcuff to keep us in an NHS post for 5-10 years post qualification. That will only reduce numbers coming in the door or poor students attending. The thing is where would such a policy end? Teachers? Nurses? Police? Anyone who works in the public sector should pay back all their education fees? What about those working in private sector, they are using taxpayer education to profit someone else, is that right? Does this mean that nobody should get state funded education? Having a well trained workforce is good for the country but there needs to be good enough jobs to keep people there.
Here I will put paid to the myth that your taxes pay for all my post graduate training is not good value for money. Whilst HEE pay some of my salary I can guarantee you that the time I spend in post graduate "training" is actually spent providing a service at a cut price. All the discharge paperwork, cannulas, radiology forms, coding paperwork actually contributes to the running of the service, not just my "training". So beware people who quote £500k as a training figure as that includes my salary for all my years in training. Of course, my post graduate "training" isn't passively looking over a consultants shoulder and absorbing knowledge. A lot of service work goes into it as well. If I do an appendicectomy at 2am on my own, am gobbling up your money being trained? Or am I actually providing a service within the remit of my current skills?
What is your solution?
Unless enforced ill health, misadventure or a better long term alternative comes along, I won't give up my National Training Number. This puts me in somewhat weak position with regards to the new contract. Now I have a family and a mortgage and am not yet a consultant so I can't just up sticks and leave for Oz like last time. So whatever happens I'll be at work in August. I can't say the same for my colleagues. In my department alone we have 1 going to Scotland, 1 moving abroad and 1 leaving medicine all together. I know the plural of anecdote isn't evidence but I did a teaching session for our 14 FY2 doctors last week. More of them were moving away, locumming or taking time out than staying for a specialty post. Maybe a zero hour, poorly trained cohort of juniors is what the government want?
Next BMA action could be to not sign any one up to a new post in August and instead form a locum agency to outsource trusts own doctors back to them at locum rates. Then nobody has to strike and it will show you how much a medical workforce could cost. Indefinite emergency only care is an option but suffers the same problems that caused me to scab this time. We could work with the deaneries to give all trainees 3 months "out of program experience" so nobody had to lose their training numbers and nobody starts work on August 5th. This is difficult to achieve seeing as HEE is a government agency.
The NHS is a monopoly employer so I can't just go and work and train at the hospital down the road.
Do you want to bring down the government?
Well, Yes. I'm a member of a political party which isn't the conservative party, so seeing the government brought down would be great. Just not over the JD contract dispute. There are lots of reasons not to like what is going on in the current government, but it's not out of character is it? People knew what they were voting for and they're getting it.
New junior doctor contract is a pay cut: A proof
I have a 1:8 rota where I work 7 nights (8pm-8.30am) every 8 weeks and 1 Saturday and 1 Sunday day shift every 8 weeks (8am-8.30pm). I also work 5 long weekdays every 8 weeks(8am-8.30pm). Every other day is a normal working day or rest day. As far as I know our department is not planning to change the rota despite the need for 7 day services. I therefore will be working the same hours in August as I am on now. Our rota is EWTD compliant, i.e. we work no more than 48 hours per week on average. Just for the record, I've worked a very similar 1:7, 1:8 or 1:9 rota in every hospital job I have had in the UK, so I don't work a particularly unusual or busy rota, I'm not in the small minority.
Prove by contradiction that new contract will result in a pay.
I will use the assumption that I will not get a pay cut.
Current pay = Proposed pay
Current pay is a 50% banded job = 1.5x (x = basic salary for 40h/wk normal working days)
Proposed pay: (source NHSE)
Nights attract 50% uplift
Sundays attract 30% uplift
87.5 of my 384 (48hrs per week x 8weeks) hours over an 8 week period are nights. ~23% which attract 50% uplift
and 12.5 of my 384 hours over an 8 week period are long day Sundays. ~3% which attract 30% uplift
No uplift is attracted for weekday long days or Saturday long days. This means 74% of my hours attract normal rate.
New basic salary = y = 1.135x (13.5% payrise)
Proposed Pay breakdown: 0.74y + [0.23 (1.5y)] + [0.03(1.3y)]
multiplying out gives us:
0.74y + 0.34y + 0.039y = 1.119y
substituting y = 1.135x
New pay = 1.27x
1.27x =/= 1.5x
I'm OK for 3 years as my pay protection is worth the ~4.8k a year I will lose. This is an appreciable amount of money. This is stated very clearly on my NHSE pay calculator. This won't help the new doctors starting this year or doctors coming from abroad who will be worse off than I am, despite doing the same job.
Not fair is it?
We were very excited recently when Chris Bradfield from Soundscommercial uncovered a previously unseen batch of EIAJ half inch reel to reel video tapes. In the process of looking for 1976 footage for their event, Sprit of 76, we uncovered many other gems. One of these goals was the famous hat-trick scored by Kevin Mabbutt against Manchester United at Old Trafford in 1978. Mabbutt is one of only two players in Football League history even to have done this and this footage was never recorded anywhere else!
Unfortunately this large batch of valuable recordings had been stored in damp, unheated conditions and had suffered. The tape had deteriorated in several ways.
- Mould growth was evident on some tapes
- The oldest tapes from the early 1970’s were shedding oxide severely and had little lubrication left in the binder.
- Binder hydrolysis, often called sticky shed was evident on other tapes.
Each issue needed a different process to treat the tape. The common assumption that ‘tape baking‘ will restore all unplayable tape is not true. It is just one solution to one of these issues and can cause more problems if used incorrectly. Deteriorated video tape is much less forgiving than audio tape when attempting transfer and must always be handled and processed with extreme care. Crinkled, curled, edge damaged tapes are next to impossible to restore back to their original condition and it’s common that more damage can occur when owners are desperate to transfer footage.
We were able to restore all the tapes to a playable condition and make uncompressed quicktime files of these.
Below is a clip from a later recording. We are not able, unfortunately, to show the Kevin Mabbutt clip yet.
Tags: Bristol, EIAJ, tape mould, video reel
This entry was posted on Tuesday, March 8th, 2011 at 1:21 pm and is filed under Video Tape. You can follow any responses to this entry through the RSS 2.0 feed.You can leave a response, or trackback from your own site.